British Journal of Biomedical Science

ISSN: 0967-4845 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/tbbs20

Potential pathogenic aspects of denture plaque

L. Coulthwaite & J. Verran

To cite this article: L. Coulthwaite & J. Verran (2007) Potential pathogenic aspects
of denture plaque, British Journal of Biomedical Science, 64:4, 180-189, DOI:
10.1080/09674845.2007.11732784

To link to this article: http://dx.doi.org/10.1080/09674845.2007.11732784

Published online: 23 May 2016.

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 180 REVIEW ARTICLE
Potential pathogenic aspects
of denture plaque
L. COULTHWAITE and J. VERRAN
School of Biology, Chemistry & Health Science, Manchester Metropolitan
University, Manchester, UK
Accepted: 13 November 2007
Oral health of the elderly
Oral healthcare is not adequately considered in most
British Journal of Biomedical Science 2007.64:180-189.
protocols outlining maintenance of personal hygiene and
general health for the elderly in hospitals, long-term care
units or intensive care units, and is poorly addressed by
health policies aimed at the community-living elderly.1–3 Oral
health, although rarely life-threatening, plays an essential
role in the quality of life,4 management of medical problems,
nutrition, and social interaction of the elderly.5 High-risk
groups for oral diseases include old people in institutions or
those who are functionally dependent for activities for daily
living.6
There have been few studies on the provision of oral care
for denture-wearing populations. This is particularly
important for the debilitated elderly receiving domiciliary
visits (or not), those in long-term institutional care such as
hospitals, and those in nursing homes who depend on
healthcare personnel or family members for their oral
care.1,3,7,8 Stroke results in coordination, sensory or cognitive
deficits and has an impact on independent oral care, yet in
only 49/70 stroke-care settings surveyed were staff expected
to clean patients’ dentures.8
In a single study, 96% of nursing home staff questioned
felt that oral healthcare of the elderly was very important
and 96.2% indicated dentures should be cleaned at least
once a day and rinsed after every meal.9 However, this is
only an indication of positive thinking and does not indicate
implementation. Intervention on oral cleanliness of long-
term hospitalised elderly in a single study led to improved
denture hygiene and the recommendation that organised
oral health education of nursing staff should receive more
attention.10
Malnutrition in the elderly is a particular problem in
institutional settings, with reported frequencies in geriatric
patients of 30–60%.11 An association has been reported
between malnutrition and the presence of oral candidosis,11
which in turn results in mucosal lesions, decreased energy
intake, and subsequently worsening nutritional status. The
provision of daily oral care for nursing home residents can
Correspondence to: Professor J. Verran
School of Biology, Chemistry & Health Science, Manchester Metropolitan University
John Dalton Building, Chester Street, Manchester, M1 5GD
Email j.verran@mmu.ac.uk
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)
ABSTRACT
Oral health status declines with age and as a result the
need for removable prostheses increases. Oral health is a
reflection of one’s general health, affecting the ability of an
individual to eat and speak, and contributes significantly to
a sense of confidence and well-being. Currently, there are
15 million denture wearers in the UK, representing a
significant consumer base and a special healthcare
consideration. The microbiology of denture plaque has
received little attention in comparison with dental plaque,
yet it differs in location and composition. Denture plaque
and poor denture hygiene is associated with stomatitis
(Candida infection), may also serve as a reservoir of
potentially infectious pathogens, and may contribute to
oral malodour and to caries and periodontitis in people
who have remaining natural teeth. Oral bacteria have been
implicated in bacterial endocarditis, aspiration pneumonia,
gastrointestinal infection and chronic obstructive
pulmonary disease, among others, and dentures offer a
reservoir for microorganisms associated with these
infections. An effective oral hygiene regimen is important
to control denture plaque biofilm and contributes to the
control of associated oral and systemic diseases.
KEY WORDS: Denture.
Plaque.
Oral health.
prevent aspiration pneumonia, improve appetite, and
enhance quality of life. Despite this, in a single study of an
acute-care long-term hospital for the elderly, only 30% of
caregivers interviewed had received specific training in
elderly oral care,6 accounting for the lack of implementation
of oral hygiene protocols.
An unhygienic oral environment, resulting in plaque-
associated oral diseases such as inflammatory gingivitis and
periodontitis, can affect systemic health negatively and may
contribute to initiation and/or progression of certain lung
diseases.12 Most bacterial pneumonias occur by aspiration of
bacteria colonising the oropharynx or upper gastrointestinal
tract of the patient, and the debilitated are at the greatest risk
for developing pneumonia. The most commonly isolated
organisms from invasive bronchial specimens, blood
cultures, pleural fluid and serology of intubated nursing
home residents were Staphylococcus aureus (29%), enteric
Gram-negative rods (15%, predominantly Klebsiella
pneumoniae and Escherichia coli), Streptococcus pneumoniae (9%)
and Pseudomonas aeruginosa (4%), with a fatality rate of 57%.13
In a single study, potential respiratory pathogens
colonised dental plaque in 64.5% of the dependent elderly
surveyed, thus plaque was considered a specific reservoir for
colonisation and subsequent aspiration pneumonia of the

a b
Fig. 1. Plaque on a complete maxillary denture: (a) before and (b) after disclosing with PlaqueFinder, showing plaque accumulation
at (i) the tooth-gum interface and (ii) interproximal regions, red indicating old and blue newer plaque.
dependent elderly.14 Approximately 60% of cases of hospital-
acquired pneumonia are caused by aerobic Gram-negative
bacteria, particularly the Enterobacteriaceae; however,
Staphylococcus aureus and other Gram-positive cocci
including Streptococcus pneumoniae have emerged as
important isolates.15 Literature review suggests respiratory
British Journal of Biomedical Science 2007.64:180-189.
pathogens preferentially colonise teeth or dentures, rather
than soft tissue.16,17 Thus, it is important that the aspiration of
opportunistic pathogens in the elderly is kept to a minimum
through effective oral healthcare practices.
A recent report on ageing by the Wellcome Trust18 omits
any mention of oral health, and this is a major failing as oral
health affects diet and nourishment, social interactions and
self-confidence, and has been shown to be an important risk
factor in associated systemic diseases. Further studies are
required on the oral health of the elderly, as this is an
important yet neglected area of geriatric medicine and
dentistry. It is important to ensure that the extra years of life
that people are gaining are as healthy, productive and
enjoyable as possible. As lifespan lengthens, there is a fear
that so too will the period of illness at its end.18
Denture-wearing population
Preservation of the dentition into old age has become more
common in recent decades,19 and this can be used as an
indicator of the oral health of a population. As a result of
improvements in health and medical care, life expectancy is
continuing to increase,20 resulting in an increasingly elderly
population in many developed countries. In Japan, it is
predicted that the elderly will comprise over 25% of the total
population by 2025.21
Oral health status declines with age, and as a result the
need for removable prostheses increases. Thus, there will be
a denture-wearing population for some time to come.
Removable prostheses include full or partial maxillary
(upper jaw) or mandibular (lower jaw) dentures. Although
the proportion of people reliant on dentures is decreasing,
over 25% of people in the UK wear complete or partial
dentures.19 Currently, there are 15 million denture wearers in
the UK, with 120,000 edentulous people. Of these,
approximately 40% wear full dentures, 20% wear one full
denture only, 17% wear one full and one partial denture,
and 23% wear partial dentures only.22
Although over 69% of edentate people in the UK are aged
over 65 years,19 the overall population wearing dentures
presents a wide age and health range. Many of these
Pathogenic aspects of denture plaque 181
i
ii
individuals are healthy and active, while others are infirm.
The former represent a significant consumer base, primarily
for aesthetic purposes, while the latter require simple and
effective non-mechanical methods for maintaining oral
hygiene such that the debilitated elderly (and/or their carers)
can maintain control of their oral healthcare.22
Oral environment in denture wearers
The oral cavity provides a diverse range of surfaces
including soft, shedding, non-keratinised buccal mucosal
epithelia, the keratinised mucosa of the gums, the
specialised, highly papillated mucosa of the tongue, and the
hard, non-shedding surfaces of the teeth. In comparison
with the dentate individual, the mouth of the denture
wearer presents additional hard, non-shedding areas and
new environments (tissue-fitting surfaces) to support the
growth of microorganisms and the development of plaque.
Dentures accumulate plaque, stain and calculus in a way
similar to natural teeth (Fig. 1).23
There are microbiological problems associated specifically
with denture wearing that have been relatively neglected.
These include the aesthetic appearance of the false teeth
(e.g., presence of staining and calculus; Fig. 2), oral/denture
hygiene, damage to oral tissues, caries, gingivitis and
periodontitis in the remaining teeth of partially dentate
subjects where plaque builds up at the abutment site
(Fig. 3),24–26 denture-related stomatitis and halitosis. The
denture may also act as a reservoir of infection for
respiratory and systemic opportunistic pathogens,16,17 and
presents a niche for antibiotic-resistant bacteria.27,28
Xerostomia (dry mouth) is common in elderly
populations, affecting denture retention and the microbial
flora. Loss of fit of the prosthesis due to alveolar bone
resorption (resulting from the loss of adjacent natural teeth)
may increase inflammation and also affect denture retention
during speech and eating. There is also a lack of work on
partial denture wearers to compare the adjacent microbial
plaque biofilms on the dentures and remaining natural
teeth.
Dentures are made of synthetic polymers, primarily
polymethylmethacrylate (PMMA), and sometimes are used
with soft liners and tissue conditioners to improve comfort
and fit and to reduce irritation on the mucosa. Denture soft
lining materials such as silicone are flexible in order to
provide cushioning of the hard denture acrylic base and
hence are more permeable with more porous structures and
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)
 182 Pathogenic aspects of denture plaque
a b
Fig. 2. Plaque and calculus (arrowed) on the buccal surface above the molars of a complete maxillary denture
(a) before and (b) after disclosing with PlaqueFinder.
more depressions in which cells may be retained. 29
Therefore, these silicone materials are more susceptible to
microbial colonisation and penetration, resulting in
deterioration and loss of functional properties.30
Modification of denture materials to reduce attachment is
an active area of dental research, although little has yet
British Journal of Biomedical Science 2007.64:180-189.
reached the market. For example, reduced surface
roughness31 and hydrophobic modification32 of silicone soft-
liners can decrease adhesion and subsequent colonisation,
particularly by Candida albicans.
Removable dentures can undergo harsher cleaning
regimes than is safe for the natural dentition because they
can be removed from the mouth. However, many denture
wearers do not remove their dentures for cleaning, and this
is a major periodontitis and caries risk in partial denture
wearers,24 and is also associated with increased prevalence of
stomatitis in complete denture wearers.33
Research highlighting plaque accumulation ‘hot spots’,
demonstrating poor oral hygiene, and the colonisation of
potential pathogens on the dentures might encourage a
change in the perception of denture wearers regarding their
oral hygiene procedures. There are, therefore, fundamental
benefits for both complete and partial denture wearers in
terms of the detection and subsequent removal of plaque.
Education on, and maintenance of, good oral hygiene and
health status is essential for denture wearers (and/or their
carers).
It is important to distinguish between the bacterial species
associated with health and disease, but many known
pathogenic bacteria are present in a healthy mouth,34 and,
a b
Fig. 3. Partial maxillary denture (a) before and (b) after disclosing
with PlaqueFinder showing plaque accumulations (arrows) on the
denture tooth at the abutment site that contacts the remaining
natural teeth in the mouth.
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)
according to the ecological plaque hypothesis,35 it may be the
proportions of pathogens present that cause the change
from health to disease, rather than the presence or absence
of particular species. It is also important to know which
microorganisms are present in the oral cavity for diagnosis
and rational treatment of systemic as well as oral diseases.36
Plaque control on the fitting surface is difficult to
maintain,3,37–39 due to the rough surface topography where
plaque retention and accumulation is enhanced.30 This
highlights the need for effective chemical cleansers coupled
with physical removal.
The bacterial flora of saliva in edentulous patients wearing
dentures may be derived from bacteria colonising the
dentures as well as those from the oral mucous membranes,
mainly the tongue.40 The natural flow of saliva, and
mastication, detaches microbes not attached firmly to oral
surfaces, but the environment beneath a denture will be less
susceptible to these properties. Types of medication can
reduce salivary flow rate, which, along with a decrease in
host defences that may occur in old age,41 could contribute to
the increased isolation of staphylococci and enterobacteria
(not typical oral species) from the oral cavity of the elderly.
Complete denture wearers lack gingival crevices, hence
gingival crevicular fluid (GCF) and periodontal disease are
absent. Therefore, the absence of periodontal species might
be anticipated. However, in the edentulous patient, serum
released during inflammation resulting from mucosal
irritation by ill-fitting dentures may support a more diverse
community on the denture, with increased growth of more
fastidious anaerobes in the nutrient-rich niche created. Few
studies have isolated obligate anaerobes from denture
plaque. Although this may be due to these microorganisms
not being a focus in these studies, the more demanding
nutritional and atmospheric requirements necessary for
their recovery from clinical samples may be an additional
factor that contributes to reduced proportions in denture
plaque compared to mature dental plaque.
Denture plaque composition
The oral flora comprises a diverse group of microorganisms
including bacteria, fungi, mycoplasmas, protozoa and
viruses. Bacteria predominate, with an estimate of over
600 different species present in the oral cavity;42 however,
only half of these species can be cultured in the laboratory.43,44
This will be true for both dentate and edentate individuals.
Denture plaque is a dense, complex heterogeneous layer
 Pathogenic aspects of denture plaque 183

of microorganisms and their metabolites, and it contains Table 1. Number of papers identified using the keywords ‘dental’ and
more than 1011 organisms/g (wet weight).45 Denture plaque ‘denture’ in PubMed (www.ncbi.nlm.nih.gov/sites/entrez) over the last
develops from adherence, aggregation and growth of 30 years (accessed 20 October 2007).
microbes from saliva, oral mucosa and possibly fingers in the
absence of adequate denture hygiene, and derives nutrients
from saliva, oral mucosa and the diet.39 Plaque accumulates Dental Denture Total
preferentially at stagnant sites offering protection from flow 5 Years
and mechanical removal forces in the mouth,46 and the keyword 39325 2978 42303
denture provides many such sites.
& plaque 2377 113 2490
Plaque was visible before disclosing on over 50% of
dentures assessed in two recent studies,47,48 indicating a poor & microbiology 917 29 946
level of oral hygiene among denture wearers. Plaque on 10 Years
dentures acts as a film for stain deposition23 and, if left in a keyword 73589 5793 79382
particular area, may calcify and become ‘tartar’ or calculus & plaque 4531 230 4761
(Fig. 2), which requires dental scaling for removal.49 & microbiology 1845 61 1906
The microbiology of denture plaque has received little
20 Years
attention in comparison to dental plaque (Table 1) yet it
differs in terms of location (the most problematic denture keyword 149671 15105 164776
plaque occurs on the maxillary fitting surface) and & plaque 9581 521 10102
composition (increased likelihood of the presence of yeast)26 & microbiology 3801 127 3928
(Fig. 4a), but the general composition, particularly of obligate
British Journal of Biomedical Science 2007.64:180-189.

anaerobes, is ill-defined. Of the total publications containing
the keywords dental and denture, ‘dental’ publications
represent around 90%, and ‘denture’ publications around
10% – a proportion that is decreasing. With plaque as a
keyword, again ‘dental’ publications predominate (around
95%), while including the term microbiology results in a
further decrease in the proportion of denture publications to
just 3%. Numerous cultural studies have reported the
diversity of the resident oral microflora in dentate
individuals, and it is likely to be the same for denture
wearers, but further studies are warranted.
There have been relatively few studies on denture plaque
microbiology, the bulk being carried out in the 1980s on
small subject groups, with few recent studies.26 The majority
of the literature on denture plaque focuses on the
aetiological agent of denture-related stomatitis, Candida
albicans (Fig. 4a), and associated causative factors (i.e., poor
denture hygiene and subsequent plaque accumulation).26
There is general agreement that denture plaque composition
is broadly similar to that of dental plaque,26,37 with Gram-
positive cocci and short rods predominating,37,38,50–52 whereas
Gram-negative rods are relatively few in number.50,51,53
Plaque microflora varies between individuals and
30 Years
keyword 213603 26682 240285
& plaque 13567 782 14349
& microbiology 5239 173 5412
between sites in the mouth and on the denture, where
differences between the buccal flange, denture tooth, tooth
gum interface and the fitting surface have been identified.26
Ass et al.54 reported that most sites contained 20–30 different
predominant (Fig. 4b) bacterial species. This is probably a
vast underestimate due to culture compared to molecular
analysis techniques.
The predominant cultivable microflora of denture plaque
includes Streptococcus spp. (S. sanguinis [formerly S. sanguis],
S. oralis, S. anginosus, S. salivarius), Staphylococcus spp. (S. aureus,
S. epidermidis), Gram-positive rods (Actinomyces spp. [A. israelii,
A. naeslundii, A. odontolyticus], lactobacilli, Propionibacterium spp.),
Veillonella spp., Gram-negative rods and yeasts.34,37,39,53,55,56 The
apparent absence of Streptococcus mutans as a predominant
microbial species in denture plaque is important because it
can predominate in dental plaque, and is aetiologically
associated with dental caries.

a b

Fig. 4. a) Gram stain of a smear of denture plaque showing yeast blastospores, Gram-positive rods and long, slender Gram-negative
rods. b) Denture plaque mixed colonies produced on fastidious anaerobe agar with 6% horse blood after 72-h anaerobic incubation.

BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)

 184 Pathogenic aspects of denture plaque
a b
Fig. 5. Lingual surface of a mandibular denture (a) stained with PlaqueFinder and (b) QLF image of highlighted area in
(a) showing red fluorescence of the mature plaque biofilm.
In the relatively stagnant area on the tissue-fitting surface
of dentures, plaque tends to be more acidogenic, thus
British Journal of Biomedical Science 2007.64:180-189.
favouring streptococci and Candida spp., which is found
most frequently on this surface of the denture.26,57 In
addition, a higher nutrient concentration, low salivary flow
rates and roughened topography support and protect
plaque.22
Denture plaque in comparison to dental plaque was
reported to have a large proportion of obligate anaerobic
Actinomyces spp. (A. israelii), low proportions of Gram-
negative rods and the regular presence of the skin bacterium
Staphylococcus aureus.34,37,55 In a single study of denture
plaque, 27% of subjects were colonised with S. aureus, of
which only 1% were methicillin-resistant S. aureus (MRSA).28
Although this may indicate low clinical significance, it is one
of few studies specifically targeting MRSA detection.
No specific investigations into the contribution of Gram-
negative obligate anaerobes to denture plaque have been
reported. The term Gram-negative rods tends to be used as
a blanket term,50,51,53 yet this group may be important in
associated systemic diseases and periodontal diseases in
partial denture wearers, and are known to contribute to
malodour production. The presence of particular species,
notably the periodontal pathogens, pigmented Prevotella
species and Porphyromonas gingivalis, is rarely reported.
There is no evidence in the literature to indicate that
P. gingivalis has been detected from denture plaque,56 yet
Prevotella melaninogenica56 and P. intermedia38 have been
isolated. No study of the tongue flora of denture wearers
could be found in the literature.
Few molecular studies have been applied to plaque
profiling. A preliminary study has demonstrated the
successful application of polymerase chain reaction-
denaturing gradient gel electrophoresis (PCR–DGGE) to
profile bacterial communities present in healthy denture
plaque.58 This technique has been applied to study the
bacterial communities of dental plaque in health and
gingivitis59 and in endodontic infections,60 among others.
The DGGE profiles showed a considerable degree of
variability between plaque samples from different sites on
the same denture, and from different subjects.58 Importantly,
DGGE gave information about community composition
that could not be derived using culture isolation
techniques.58 A comparison between profiles of ‘pathogenic’
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)
denture plaque in comparison with ‘healthy’ denture plaque
could prove useful.
Denture plaque assessment
Measurement and assessment of plaque can provide
valuable information about an individual’s oral health
status, hygiene procedures, assessment of disease prognosis
and assessment of new treatments or products. Methods
used for assessing plaque quantity have included dry or wet
weight measurement, biochemical assays, oxygen
consumption assays, microbiological counts and visual or
planimetric assessments of plaque coverage or biofilm
thickness in situ.61–66
Fluorescence detection is a non-contact, non-destructive
technique that has received increased attention due to its
high sensitivity and specificity.67 The Quantitative Light-
induced Fluorescence (QLF) imaging system (Inspektor
Research Systems, BV) is a special dental diagnostic tool that
has been used for in vivo and in vitro quantitative assessment
of dental caries, tooth whitening, bacterial activity, calculus,
staining, and dental plaque.68,69 The technique is based on the
autofluorescence of teeth, which, when illuminated with
low-power visible blue light, emit in the green part of the
spectrum. Fluorescence light irradiation reveals differences
in enamel opacity (demineralised and sound enamel),
making earlier caries lesion detection possible. In addition,
QLF can be used to indicate the presence of plaque on teeth,
as the microorganisms fluoresce to some extent during the
process.
Denture plaque can be detected using the QLF system,70
with potential implications in oral hygiene assessment.
Areas of red and green fluorescence have been observed
from denture and dental plaque in vivo under QLF
illumination, and differences between the microbial species
at these sites has been demonstrated by culture-dependent70
and -independent58 techniques. The detection of red
fluorescent plaque using the QLF system is indicative of
black pigmented obligate anaerobes, and thus mature
plaque,70 highlighting plaque traps (Fig. 5), areas of
stagnation such as the fitting surface (Fig. 6), and proximity
to salivary duct openings (Fig. 7). Thus, detection of red
plaque deposits using the QLF system indicates areas of
 Pathogenic aspects of denture plaque 185

a b

Fig. 6. Fitting surface of a maxillary (a) stained with PlaqueFinder and (b) QLF image of highlighted area in
(a) showing red fluorescence of the mature plaque biofilm.

plaque accumulation/mature plaque, and highlights target material, where present.29 Oral candidosis development may
areas for hygiene procedures. be promoted by poorly fitting dentures and poor denture
British Journal of Biomedical Science 2007.64:180-189.

hygiene,72 along with other predisposing factors including

Problems associated with denture plaque
Stomatitis and oral candidosis
Most of the literature on denture plaque focuses on Candida
albicans and its association with denture stomatitis. Candida
is isolated more frequently from denture plaque than from
dental plaque.71–73 The most important source of Candida
species in humans is endogenous: candidoses arise in
subjects predisposed by illness, debility or local reduction in
host resistance to an overgrowth of their own yeast flora.74
Candidosis is the most common systemic mycosis,75 with
several species of Candida capable of causing infection.
Adhesion enables Candida to resist the flushing action of
saliva, and is the first stage in the process leading to
colonisation and infection, 76 making it an important
virulence factor. The rate of adhesion of Candida spp. isolated
from denture plaque to exfoliated buccal epithelial cells has
been shown to be very low,77 indicating that the major
reservoir of Candida is the denture itself, rather than the
mucosal epithelia.
Denture-related stomatitis is a condition present in
10–75% of denture wearers74,78–81 and often is linked with
acute pseudomembranous oral candidosis (thrush).82 The
main reservoirs of C. albicans and related species are the
fitting surface of the denture53,57,71,83 and soft denture lining
age, corticosteroids, broad-spectrum antibiotics and
immunosuppression.84 Generally, C. albicans is accepted as
the main aetiological agent of denture-related stomatitis;71
however, several studies have implicated bacteria and poor
denture hygiene in the disease process.52,55,57,82
Yeasts usually constitute less than 1% of the total
cultivable isolates of denture plaque,37,51 yet they contribute a
significant mass to the plaque biofilm as a result of their large
size compared with bacteria.26 It has also been suggested that
Candida infection could contribute to caries, root caries and
periodontitis of abutment teeth;45 thus, reduction of yeast
levels is of particular importance to partial denture wearers.
Malodour
Oral malodour is a common and often distressing condition
and is poorly explored in denture wearers. Owing to the
artificial nature of the denture, many edentulous patients
express concern that they may produce a distinct malodour.85
Dirty dentures contribute to malodour,23 which is generally
acknowledged in the dentate to be caused in part by volatile
sulphur compounds (VSCs), including hydrogen sulphide,
methyl mercaptan and dimethyl sulphide.86 These VSCs
cause a fetid or putrid odour and are produced by Gram-
negative bacteria, particularly anaerobic species such as
Porphyromonas spp., Prevotella spp. and Fusobacterium spp.87,88
by proteolytic degradation of sulphur-containing peptides

a b

Fig. 7. Maxillary denture 3 buccal surface (a) undisclosed and (b) QLF image of highlighted area in (a) showing red fluorescence.

BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)

 186 Pathogenic aspects of denture plaque
and amino acids present in saliva, shed epithelium, food
debris, GCF, plaque and blood.86 These bacteria also have an
association with periodontal disease.86,87,89 Other Gram-
negative bacteria found in denture plaque, such as Klebsiella
spp., may be potential pathogens in respiratory or systemic
diseases arising from the oral reservoir of microorganisms.
Little work has been published on denture-associated
malodour, but many species capable of producing
malodorous compounds are found in denture plaque.22
Dentures are particularly important causes of oral malodour
if they are worn overnight;90 thus, frequent plaque removal
and denture cleaning is important to reduce denture-
associated malodour. Many denture cleansing products
claim breath-freshening properties, yet this has not been
investigated specifically. Indeed, it is more likely that any
odour is ‘masked’ rather than reduced. The role of yeasts,
decreased salivary flow, the nature of tongue flora in
edentulous individuals, colonisation of the denture, and the
presence of soft liners on denture-associated malodour are
unknown. The profile of denture malodour in the presence
and absence of yeast in the plaque as yet is undefined.
British Journal of Biomedical Science 2007.64:180-189.
Reservoir of infection
Recently, there has been an increase in the number of studies
investigating the link between oral and systemic diseases in
the dentate14,91,92 and edentate.7,16,21,45 Oral bacteria have been
implicated in bacterial endocarditis,90 aspiration pneumonia,92–94
gastrointestinal infection17 and chronic obstructive pulmonary
disease93 among others, and dentures offer a reservoir for
microorganisms associated with these infections.
Dentures may spend time in a non-hygienic environment
when out of the mouth and may also harbour
microorganisms not normally associated with the oral flora,
including Streptococcus pneumoniae, Haemophilus influenzae,
Neisseria meningitidis, certain Enterobacteriaceae22,26 including
E. coli, Klebsiella spp.16,83 and Pseudomonas spp., and
staphylococci including, but rarely, MRSA. 27,28 Such
organisms may be considered respiratory pathogens and
have been reported to colonise the denture plaque in 46% of
the dependent elderly.16 Hospital and institutionalised
denture wearers may be at increased risk of cross-
contamination when healthcare workers handling the
dentures do not take adequate hygiene measures.
The continuous swallowing or aspiration of
microorganisms from denture plaque exposes patients,
particularly the immunocompromised host or medicated
elderly, to the risks of unexpected infection;21,45 thus, the role
of the denture in harbouring such organisms may be
significant. Respiratory diseases, particularly pneumonia,
are responsible for significant morbidity and mortality in
human populations. Oral bacteria may be inhaled directly,
organisms in plaque shed in the saliva, and small droplets
aspirated into the lungs where bacterial enzymes decrease
protection against colonisation.93
Residents in institutional situations for extended periods
of time, such as long-term hospital patients or nursing home
residents, have increased exposure to pathogens (including
drug-resistant strains), are less likely to have good oral
hygiene and are more likely to have poor general health.93 It
is reported that a relationship exists between poor oral
health, oral microflora and bacterial pneumonia.92,94 In order
to reduce the load of endogenous microorganisms in the oral
cavity, mechanical removal of plaque biofilms is essential.92
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)
Hygiene
Denture plaque and poor denture hygiene are suggested to
be the principal causes leading to severe inflammation of the
palatal mucosa23,95,96 and to denture-related stomatitis,72,78,80,96,97
thus indicating the importance of maintaining good denture
hygiene and the efficacy of denture cleansing products.
Denture cleanliness is essential to prevent malodour, poor
aesthetics and accumulation of plaque and calculus.22,23,96 For
denture wearers in comparison to the dentate, less attention
has been paid to the importance of plaque control and
removal.98 The change from healthy to diseased plaque may
be a natural progression in the absence of adequate hygiene
procedures, where a nutrient-rich niche is created.26 In the
absence of oral hygiene in the dentate, gingivitis ensues,99 so,
in the absence of denture hygiene, it may follow that
denture stomatitis would be equally inevitable.26
Only a limited number of people maintain effective oral
hygiene, and the majority of denture wearers are failing to
keep their dentures clean.1,81,95,100 Although it is recommended
that dentures be removed at night,25,101 this is often not the
case,19 and wearing dentures overnight has been associated
with poor oral heath in comparison to day-wearing of
dentures only.24,80
Mechanical plaque removal and control and good
denture-wearing habits, including regular check-ups, are the
most important measures in the prevention and treatment of
denture-induced stomatitis.78 It has been recommended that
denture wearers should be instructed and motivated to
brush.23 Brushing with a paste or soap is the most common
form of denture cleaning;23,100 however, this demands manual
dexterity beyond the ability of many geriatric or physically
or mentally handicapped individuals.
A denture-cleansing product should be easy to use,
remove organic and inorganic plaque deposits effectively, be
bactericidal and fungicidal, and non-toxic.102 Additionally, it
should clean tough stains and control denture odour while
being gentle on the acrylic (no whitening or abrading).
Currently, commercially available denture cleansers include
alkaline peroxides, alkaline hypochlorites, dilute acids
(1.6–1.8 M HCl or H3PO4), disinfectants and enzymes.
Mechanical methods of cleaning dentures include abrasive
pastes or powders, microwaving82 and ultrasonication.103 For
elderly denture wearers, chemical soaks are the method of
choice.97,104,105
Coulthwaite et al,106 developed a model denture plaque
biofilm in a constant-depth film fermenter (CDFF) that can
be used to evaluate antimicrobial efficacy of denture
cleansers in vitro, and showed that a range of commercially
available cleansers were equally successful at plaque
viability reduction. This provided a more readily accessible
plaque consortium than denture plaque, and is more valid
than current models using batch cultures of pooled healthy
dentate saliva. Although all products were equally successful
at total microbial count reduction, cleaning did not reduce
Candida spp. levels significantly;106 a finding that has
significant implications for the ability of these products to act
effectively in prevention and control of denture-related
stomatitis suffered by the majority of denture wearers at
some time. Some denture plaque microorganisms are known
to contribute to oral malodour.22 During pilot studies, an
odour dissimilar to oral malodour, was detected on the
prostheses (rather than the breath),56 the nature and origin of
which merit further exploration.

Dental caries (with periodontal disease) is one of the most
common human diseases and affects the vast majority of
individuals, including partial denture wearers. Bone
resorption is a particular problem in denture wearers,
resulting in ill-fitting dentures, reduction in structural
support, and ultimately the need for new dentures to be
fitted. Therefore, detection and characterisation of denture
plaque is important for overall oral health.
For all individuals, it is important to visit the dentist for
monitoring of general oral health, as well as denture
assessment.
Discussion
Denture hygiene has not really changed to any extent for
some decades. There have been few recent studies and little
use of new technologies to investigate plaque removal and
denture cleanser efficacy. The focus needs to be on removal
of the prostheses for effective denture cleansing regimes
involving both chemical soaks for penetration and loosening
British Journal of Biomedical Science 2007.64:180-189.
of plaque and calculus, combined with brushing to remove
the biofilm from the denture surface. The development of
new denture cleansing products and methods of use should
address the different consumer groups (the active and
debilitated elderly) of denture wearers.
There is a need for more large and comprehensive studies
on the oral flora of the elderly. Current knowledge in the field
often relies on older publications, using relatively few samples
and targeting specific microorganisms. Modern molecular
methods such as denaturing gradient gel electrophoresis have
demonstrated differences in the total flora, cultivable and
otherwise, from different sites on the denture, which, coupled
with DNA sequencing, might enable further characterisation
of the composition of denture plaque, and the identification of
a less potentially ‘pathogenic’ denture plaque flora.
Knowledge of denture plaque microbiology may contribute
not only to better oral health but also to improved systemic
health and well-being. 5 21
References
1 Pietrokovski J, Azuelos J, Tau S, Mostavoy R. Oral findings in
elderly nursing home residents in selected countries: oral
hygiene conditions and plaque accumulation on denture
surfaces. J Prosthet Dent 1995; 73: 136–41.
2 Peltola P, Vehkalahti MM, Wuolijoki-Saaristo K. Oral health and
treatment needs of the long-term hospitilised elderly.
Gerodontology 2004; 21: 93–9.
3 de Visschere LM, Grooten L, Theuniers G, Vanobbergen JN.
Oral hygiene of elderly people in long-term care institutions – a
cross-sectional study. Gerodontology, 2006; 23: 195–204.
4 Locker D. Deprivation and oral health: a review. Community
Dent Oral Epidemiol 2000; 28: 161–9.
5 McGrath C, Bedi R. The importance of oral health to older
people’s quality of life. Gerodontology, 1999; 16: 59–63.
6 Gil-Montoya J, Ferreria de Mello AL. Cardenas CB, Lopez IG.
Oral health protocol for the dependent institutionalised elderly.
Geriatr Nurs 2006; 27 (2): 95–101.
7 Mojon P, Budtz-Jorgensen E, Michel J-P, Limeback H. Oral health
and history of respiratory tract infection in frail institutionalised
elders. Gerodontology 1997; 14 (1): 9–16.
Pathogenic aspects of denture plaque 187
8 Talbot A, Brady M, Furlanetto DLC, Frenkel H, Williams BO.
Oral care and stroke units. Gerodontology, 2005; 22: 77–83.
9 Thean H, Wong ML, Koh H. The dental awareness of nursing
home staff in Singapore – a pilot study. Gerodontology 2007; 24:
58–63.
10 Peltola P, Vehkalahti MM, Simoila R. Effects of 11-month
interventions on oral cleanliness among the long-term
hospitilised elderly. Gerodontology, 2007; 24 (1): 14–21.
11 Paillaud E, Merlier I, Dupeyron C, Scherman E, Poupon J, Bories
P-N. Oral candidiasis and nutritional deficiencies in elderly
hospitialised patients. Br J Nutr 2004; 92: 861–7.
12 Raghavendran K, Mylotte JM, Scannapieco FA. Nursing home-
associated pneumonia, hospital-acquired pneumonia and
ventilator-associated pneumonia: the contribution of dental
biofilms and periodontal inflammation. Periodontology 2000 2007;
44: 164–77.
13 El-Solh A, Sikka P, Ramadan F, Davies J. Etiology of severe
pneumonia in the very elderly. Am J Respir Crit Care Med 2001;
163: 645–51.
14 Sumi Y, Miura H, Michiwaki Y, Shuichiro N, Nagaya M.
Colonisation of dental plaque by respiratory pathogens in
dependent elderly. Arch Gerontol Geriatr 2007; 44 (2): 119–24.
15 Centers for Disease Control and Prevention. Guidelines for
prevention of nosocomial pneumonia, MMWR 1997; : 1–79.
16 Sumi Y, Miura H, Sunakawa M, Michiwaki Y, Sakagami N.
Colonisation of denture plaque by respiratory pathogens in
dependent elderly. Gerodontology, 2002; 19: 25–9.
17 Sumi Y, Kagami H, Ohtsuka Y, Kakinoki Y, Haruguchi Y,
Miyamoto H. High correlation between the bacterial species in
denture plaque and pharyngeal microflora. Gerodontology, 2003;
20 (2): 84–7.
18 Wellcome Focus. Ageing: can we stop the clock?
www.wellcome.ac.uk/wellcomefocus, 2006.
19 Kelly M, Steele J, Nuttall N et al. Adult dental health survey: oral
health in the United Kingdom 1998. The Government Statistical
Service, 2000.
20 Oeppen J, Vaupel JW. Broken limits to life expectancy. Science
2002; 296: 1029–31.
Senpuku H, Sogame A, Inoshita E, Tsuha Y, Miyazaki H, Hanada
H. Systemic diseases in association with microbial species in oral
biofilm from elderly requiring care. Gerontology 2003; 49: 301–9.
22 Verran J. Malodour in denture wearers: an ill-defined problem.
Oral Dis 2005; 11 (Suppl 1): 24–8.
23 Neill D. A study of materials and methods employed in cleaning
dentures. Br Dent J 1968; 124 (3): 107–15.
24 Budtz-Jørgensen E. Prognosis of overdenture abutments in the
aged: effect of denture wearing habits. Community Dent Oral
Epidemiol 1992; 20: 302–6.
25 Budtz-Jørgensen E. Effects of denture-wearing habits on
periodontal health of abutment teeth in patients with
overdentures. J Clin Periodontol 1994; 21: 265–9.
26 Verran J. Denture plaque, denture stomatitis and the adhesion
of Candida albicans to inert materials. In: Busscher HE ed. Oral
biofilms and plaque control. Amsterdam: Harwood, 1999: 175–191.
27 Smith AJ, Brewer A, Kirkpatrick P et al. Staphylococcal species in
the oral cavity from patients in a regional burns unit. J Hosp
Infect 2003; 55: 184–9.
28 Lewis N, Ready D, Howlett J, Lee D, Cookson B, Wilson M.
Culture-dependant detection of MRSA in angular chelitis.
J Dent Res 2006; 85 (Spec Issue C): Abstract 0401
www.dentalresearch.org.
29 Allison RT, Douglas WH. Micro-colonisation of the denture-
fitting surface by Candida albicans. J Dent 1973; 1 (5): 198–201.
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)
 188 Pathogenic aspects of denture plaque
30 Verran J, Maryan CJ. Retention of Candida albicans on acrylic
resin and silicone of different surface topography. J Prosth Dent
1997; 77: 535–9.
31 Bulad K, Taylor RL, Verran J, McCord JF. Colonization and
penetration of denture soft lining materials by Candida albicans.
Dent Mater 2004; 20: 167–75.
32 Price C, Williams DW, Waters MGJ et al. Reduced adherence of
Candida to silane treated silicone rubber. J Biomed Mater Res B
Appl Biomater 2005; 74: 481–7.
33 Zissis A, Yannikakis S, Harrison A. Comparison of denture
stomatitis prevalence in 2 population groups. Int J Prosthodont
2006; 19 (6): 621–5.
34 Marsh P, Martin MV. Oral microbiology. Oxford: Wright, 1999.
35 Marsh PD. Microbial ecology of dental plaque and its
significance in health and disease. Adv Dent Res 1994; 8 (2):
263–71.
36 Paster B, Boches SK, Galvin JL et al. Bacterial diversity in human
subgingival plaque. J Bacteriol 2001; 183 (12): 3770–83.
37 Theilade E, Budtz-Jorgensen E, Theilade J. Predominant
cultivable microflora of plaque on removable dentures in patients
with healthy oral mucosa. Arch Oral Biol 1983; 28 (8): 675–80.
British Journal of Biomedical Science 2007.64:180-189.
38 Gusberti F, Gada TG, Lang NP, Geering AH. Cultivable
microflora of plaque from full denture bases and adjacent
palatal mucosa. J Biol Buccale 1985; 13 (3): 227–36.
39 Theilade E, Budtz-Jorgensen E. Predominant cultivable
microflora of plaque on removable dentures in patients with
denture-induced stomatitis. Oral Microbiol Immunol 1988; 3: 8–13.
40 Socransky S, Manganiello SD. The oral microbiota of man from
birth to senility. J Periodontol 1971; 42: 485–94.
41 Marsh PD. The oral microflora - friend or foe? Can we decide?
Int Dent J 2006; 56 (4 [Suppl 1]): 233–9.
42 Kazor C, Mitchell PM, Lee AM et al. Diversity of bacterial
populations on the tongue dorsa of patients with halitosis and
healthy patients. J Clin Microbiol 2003; 41 (2): 558–63.
43 Wilson MJ, Weightman AJ, Wade WG. Applications of molecular
ecology in the characterisation of uncultured microorganisms
associated with human disease. Rev Med Microbiol 1997; 8:
91–101.
44 Wade W, Spratt DA, Dymock D, Weightman AJ. Molecular
detection of novel anaerobic species in dentoalveolar abscesses.
Clin Infect Dis 1997; 25 (Suppl 2): S235–236.
45 Nikawa H, Hamada T, Yamamoto T. Denture plaque – past and
recent concerns. J Dent 1998; 26 (4): 299–304.
46 Marsh PD. Dental plaque as a microbial biofilm. Caries Res 2004;
38: 204–11.
47 Coulthwaite L, Pretty IA, Smith PW, Higham SM, Verran J. QLF
of denture paque: red fluorescence has microbiological origin.
J Dent Res 2005; 84 (Spec Issue B): Abstract 0093
www.dentalresearch.org
48 Verran J, Smith PW, Higham SM, Coulthwaite L. Comparison of
methods for planimetric assessment of denture plaque.
J Dent Res 2006; 85 (Spec Issue C): Abstract 0523
www.dentalresearch.org
49 Sagal P, Lapujade PG, Miller JM, Sunberg RJ. Objective
quantification of plaque using digital image analysis. In: Faller R
ed. Assessment of oral health. Basal: Karger, 2000: 130–43.
50 Theilade J, Budtz-Jorgensen E. Electron microscopic study of
denture plaque. J Biol Buccale 1980; 8: 287–97.
51 Budtz-Jørgensen E, Theilade E, Theilade J, Zander HA. Method
for studying the development, structure and microflora of
denture plaque. Scand J Dent Res 1981; 89 (2): 149–56.
52 Koopmans ASF, Kippuw N, de Graff J. Bacterial involvement in
denture-induced stomatitis. J Dent Res 1988; 67 (9): 1246–50.
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)
53 Budtz-Jørgensen E, Theilade E. Regional variations in viable
bacterial and yeast counts of 1-week old denture plaque in
denture induced stomatitis. Scand J Dent Res 1983; 91: 288–95.
54 Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the
normal bacterial flora of the oral cavity. J Clin Microbiol 2005;
43 (11): 5721–32.
55 Harding S, Wilson M, Dickinson C, Hobkirk J. The cultivable
microflora of denture plaque from patients with denture-
induced stomatitis. Microbial Ecol Health Dis 1991; 4: 149–57.
56 Coulthwaite L, Verran J. Denture plaque: a neglected biofilm. In:
Allison D, Verran J, Spratt D, Upton M, Pratten J, McBain A eds.
Biofilms: persistence and ubiquity. Manchester: The Biofilm Club,
2005: 311–22.
57 Verran J. Preliminary studies on denture plaque microbiology
and acidogenicity. Microbial Ecol Health Dis 1988; 1: p. 51–5.
58 Coulthwaite L, Smith PW, Higham SM, Verran J, Detection of
bacterial populations in denture plaque using DGGE. J Dent Res
2006; 85 (Spec Issue C): Abstract 0522, www.dentalresearch.org
59 Gafan G, Lucas V, Wilson M, Spratt D. Community analysis of
the microflora of dental plaque associated in health and
gingivitis via a denaturing gradient gel electrophoresis
approach. In: McBain A, Allison D, Brading M, Rickard A,
Verran J, Walker J eds. Biofilm communities: order from chaos?
Cardiff: BioLine, 2003: 155–64.
60 Siqueira J, Rocas IN, Rosado AS. Investigation of bacterial
communities associated with asymptomatic and symptomatic
endodontic infections by denaturing gradient gel
electrophoresis fingerprinting approach. Oral Microbiol Immunol
2004; 19: 363–70.
61 Verran, J, Rocliffe MD. Feasibility of using automatic image
analysis for measuring dental plaque in situ. J Dent 1986; 14:
11–3.
62 Cardash H, Rosenberg M. An innovative method of monitoring
denture hygiene. J Prosth Dent 1990; 63 (6): 661–4.
63 Soder P.-O, Jin LJ, Soder B. Computerized planimetric method
for clinical plaque measurement. Scand J Dent Res 1993; 101:
21–5.
64 McCabe J, Murray DI, Kelly PJ. The efficacy of denture cleansers.
Eur J Prosthodont Restor Dent 1995; 3 (4): 203–7.
65 Shaloub A, Addy M. Evaluation of accuracy and variability of
scoring-area-based plaque indices. J Clin Periodont 2000; 27:
16–21.
66 Sheen S, Harrison A. Assessment of plaque prevention on
dentures using an experimental cleanser. J Prosth Dent 2000;
84 (6): 594–601.
67 Qin X, Luan XL, Bi LJ et al. Real-time detection of dental calculus
by blue LED-induced fluorescence spectroscopy. J Photochem
Photobiol B Biol 2007; 87: 88–94.
68 Van der Veen M, de Josselin de Jong E. Application of
quantitative light-induced fluorescence for assessing early caries
lesions. In: Faller R ed. Assessment of oral health. Basal: Karger,
2000: 144–62.
69 Pretty I, Edgar WM, Smith PW, Higham SM. Quantification of
dental plaque in the research environment. J Dent 2005; 33:
193–207.
70 Coulthwaite L, Pretty I, Smith PW, Higham SM, Verran J. The
microbiological origin of red fluorescence observed in denture
plaque during QLF analysis. Caries Res 2006; 40 (2): 112–6.
71 Davenport J. The oral distribution of Candida in denture
stomatitis. Br Dent J 1970; 129: 151–6.
72 Budtz-Jørgensen E. The significance of Candida albicans in
denture stomatitis. Scand J Dent Res 1974; 82: 151–90.
73 Arendorf TM, Walker DM. The prevalence and intra-oral

distribution of Candida albicans in man. Arch Oral Biol 1980;
25: 1–10.
74 Odds F. Candida and candidosis 2nd edn. London: Bailliere
Tindall, 1988.
75 Mitchell TG. Medical mycology. In: Brooks G, Butel JS, Morse SA
eds. Jawetz, Melnick & Adelberg’s Medical Microbiology. London:
McGraw Hill, 2001.
76 Douglas LJ. Adhesion of Candida albicans to host surfaces. In:
Tumbay E, Seeliger HPR, Ang O eds. Candida and candidamycosis.
New York: Plenum Press, 1991.
77 Verran J, Melvin J, Coulthwaite L. Adhesion of Candida spp.
from denture plaque to epithelial cells. J Dent Res 2007; 86 (Spec
Issue B): Abstract 0077, www.dentalresearch.org
78 Arendorf TM, Walker DM. Denture stomatitis: a review. J Oral
Rehabil 1987; 14 (3): 217–27.
79 Samaranayake LP. Host factors and oral candidosis. In:
Samaranayake LP, MacFarlane TW eds. Oral candidosis. London:
Butterworth, 1990.
80 Simons D, Kidd, EAM, Beighton D. Oral health of elderly
occupants in residential homes. Lancet 1999; 353: 1761.
81 Kulak-Ozkan Y, Kazazoglu E, Arikan A. Oral hygiene habits,
British Journal of Biomedical Science 2007.64:180-189.
denture cleanliness, presence of yeasts and stomatitis in elderly
people. J Oral Rehabil 2002; 29: 300–4.
82 Webb B, Thomas CJ, Harty DWS, Willcox MDP. Effectiveness of
two methods of denture sterilisation. J Oral Rehabil 1998; 25: 416–23.
83 Olsen I. Denture stomatitis: occurence and distribution of fungi.
Acta Odontol Scand 1974; 32: 329–33.
84 Budtz-Jørgensen E. Etiology, pathogenesis, therapy and
prophylaxis of oral yeast infections. Acta Odontol Scand 1990; 48:
61–9.
85 Fiske J, Davis DM, Horrocks P. A self-help group for complete
denture wearers. Br Dent J 1995; 178 (1): 18–22.
86 Tonzetich J. Production of oral malodor: a review of the
mechanisms and methods of analysis. J Periodontol 1977; 48 (1):
13–20.
87 Rolla G, Waaler SM, Kjaerheim V. Concepts in dental plaque
formation. In: Busscher HE ed. Oral biofilms and plaque control.
Amsterdam: Harwood Academic, 1999: 1–17.
88 Mink R, Biemer TA, Pianotti RS, Dills SS. Volatile sulphur
compound production in anaerobic oral bacteria. J Dent Res
1983; 62 (Spec Issue Abstract 91): 180.
89 Socransky S, Haffajee AD, Smith C et al. Use of checkerboard
DNA-DNA hybridisation to study complex microbial
ecosystems. Oral Microbiol Immunol 2004; 19: 352–62.
Pathogenic aspects of denture plaque 189
90 Krespi YP, Schrime MG, Kacker A. The relationship between oral
malodor and volatile sulfur compound-producing bacteria.
Otolaryngol Head Neck Surg 2006; 135: 671–6.
91 Berbari E, Cockerill FR, Steckelberg JM. Infective endocarditis
due to unusual or fastidious microorganisms. Mayo Clin Proc
1997; 72: 532–42.
92 Abe S, Ishihara K, Adachi M, Okuda K. Oral hygiene evaluation
for effective oral care in preventing pneumonia in dentate
elderly. Arch Gerontol Geriatr 2006; 43: 53–64.
93 Scannapieco FA. Role of oral bacteria in respiratory infection.
J Periodontol 1999; 70 (7): 793–802.
94 Scannapieco FA. Pneumonia in non-ambulatory patients. J Am
Dent Assoc 2006; 137 (10 Suppl): 21S–25S.
95 Budtz-Jørgensen E, Bertram V. Denture stomatitis I: The etiology
in relation to trauma and infection. Acta Odontol Scand 1970; 28:
71–92.
96 Abelson D. Denture plaque and denture cleansers. J Prosth Dent
1981; 45 (4): 376–9.
97 Nakamoto K, Tamamoto M, Hamada T. Evaluation of denture
cleansers with and without enzymes against Candida albicans.
J Prosth Dent 1991; 66 (6): 792–5.
98 Tarbet W, Axelrod S, Minkoff S, Fratarcangelo PA. Denture
cleansing: a comparrison of two methods. J Prosth Dent 1984; 51:
322–5.
99 Loe H, Theilade E, Jensen SB. Experimental gingivitis in man.
J Periodontol 1965; 36: 177–87.
100 Dikbas I, Koksal T, Calikkocaoglu S. Investigation of the
cleanliness of dentures in a university hospital. Int J Prosthodont
2006; 19 (3): 294–8.
101 British Dental Association. www.bda.org
102 Abelson D. Denture plaque and denture cleansers: review of the
literature. Gerodontics 1985; 1: 202–6.
103 Gwinnett A, Caputo L. The effectiveness of ultrasonic denture
cleaning: a scanning electron microscope study. J Prosth Dent
1983; 50: 20–5.
104 Budtz-Jørgensen E. Materials and methods for cleaning
dentures. J Prosth Dent 1979; 42 (6): 619–23.
105 Dills S, Olshan AM, Goldner S, Brogdon C. Comparison of the
antimicrobial capability of an abrasive paste and chemical-soak
denture cleaners. J Prosth Dent 1988; 60: 467–70.
106 Coulthwaite L, Sultula J, Smith R, Verran J. Susceptibility of
in vitro model denture plaque biofilms to denture
cleansers. J Dent Res 2007; 86 (Spec Issue B): Abstract 0241,
www.dentalresearch.org
BRITISH JOURNAL OF BIOMEDICAL SCIENCE 2007 64 (4)